The individual's responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, b) care coordination, c) transition planning assessment and reassessment, d) implementation or oversight of implementation of the transition plan, e) leading and facilitating multi-disciplinary patient care conferences, f) managing concurrent disputes, g) making appropriate referrals to other departments, h ) identifying and referring complex patients to Social Work Services, I) communicating with patients and families about the plan of care, j) collaborating with physicians, office staff and ancillary departments, k) leading and facilitating Complex Case Review, l) assuring patient education is completed to support post-acute needs , m) timely complete and concise documentation in Case Management system, n) maintenance of accurate patient demographic and insurance information, o) identification and documentation of potentially avoidable days, p) identification and reporting over and underutilization, q) and other duties as assigned. The RN Case Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient's resources and right to self-determination.